Prospective study of exposure to smoking imagery in films and changes in susceptibility to smoking in a cohort of school students in Southern India.

INTRODUCTION: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India. METHODS: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery. RESULTS: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, ptrend<0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility. CONCLUSIONS: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films.

Prevalence, regional patterns and socio-demographic factors associated with poly-tobacco use in India: A secondary data analysis.

BACKGROUND: Tobacco use is associated with early, intermediate and long-term complications throughout the life course. With an influx of newer products containing nicotine, poly-tobacco use is slowly emerging as a public health concern, that is defined as existing tobacco users currently using two or more tobacco or nicotine products. While many studies have investigated single use tobacco, there is a paucity of research on regional patterns and socio-demographic factors associated with poly-tobacco use in India. OBJECTIVES: To assess prevalence of poly-tobacco use and determine the socio-demographic factors associated with poly-tobacco use in India. METHODS: Data from the Global Adult Tobacco Survey 2 (GATS, 2016-17) was analysed, which included information on tobacco use among people aged >15 years. The pattern of current tobacco status was described using descriptive statistics. Multiple logistic regression models were estimated to determine factors associated with poly-tobacco use. RESULTS: The prevalence of poly-tobacco use in India was found to be 9.8%. Among the current tobacco users, the prevalence was 33%. Significant socio-demographic factors associated with poly-tobacco use included younger age, male gender, religion and backward caste. North-eastern region reported highest prevalence of poly-tobacco use in the country, followed by the central region. CONCLUSION: The number of poly-tobacco users in India is considerably high and a matter of concern, more so in north east and central regions of the country. There is a need to create awareness about dangerous effects of all types of tobacco products and strengthen implementation of tobacco control policies with special focus on regions with high burden.

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study.

OBJECTIVE: This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation. DESIGN: Qualitative semi-structured interviews. SETTING: Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically. PARTICIPANTS: Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated. RESULTS: The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation. CONCLUSION: Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Awareness, attitudes and practices relating to Article 5.3 of the WHO Framework Convention on Tobacco Control among members of tobacco control committees in a southern Indian state.

BACKGROUND AND OBJECTIVES: The tobacco industry (TI) has undermined tobacco control policy for decades. The WHO Framework Convention on Tobacco Control Article 5.3 implementation guidelines provide guidance for preventing TI interference. Government officials responsible for policy implementation must understand these guidelines to manage TI tactics. This study assessed awareness, attitudes and practices of Article 5.3 guidelines among members of District Level Coordination Committees (DLCC) in Karnataka mandated with overseeing tobacco control activity. METHOD: A semistructured questionnaire survey of awareness, attitudes and adherence to Article 5.3 guidelines among 102 DLCC members carried out between January and July 2019. RESULT: Responses were received from 82 members, comprising 51 (62%) from health and 31 (38%) from non-health departments. Our study demonstrates a lack of understanding of Article 5.3 and its guidelines, even among those actively involved in tobacco control at the district level. Nearly 80% of respondents were aware that corporate social responsibility (CSR) by tobacco companies is an indirect form of promoting tobacco. However, 44% of members felt that CSR funding from the TI should be used to combat tobacco-related harm. A higher proportion (12%) of health respondents agreed that subsidies should be provided to tobacco agriculture compared with non-health (3%). CONCLUSION: Awareness of international guidance designed to prevent the TI influence on health policy among policymakers in this Indian state is low. Respondents from non-health departments were less aware of TI CSR. Those in health departments were more receptive towards taking a TI role in the future .

Development and Validation of a New Tool to Measure Performance Knowledge and Communication Skill of Multidisciplinary Health Science Learners on Radiation Emergency Preparedness and Response Management.

OBJECTIVE: The purpose of the study was to design, develop, and validate a newer tool on radiation emergency preparedness responses (RadEM-PREM IPE tool) to measure communication, knowledge, performance skills in multidisciplinary health science learners. METHODS: The study design is a prospective, single centric, pilot study. Five subject experts designed, analyzed, and selected items of the instrument for relevant content and domain. Psychometrics that the tool assessed were content validity, internal consistency, test-retest reliability, and intraclass correlation coefficient. Twenty-eight participants completed test-retest reliability for validation of 21 sorted out items calculated percentage of agreement >70% I-CVI/UA (item content validity index with universal acceptability) and S-CVI/UA (scale content validity index with universal agreement method). RESULTS: Items with percentage agreement >70% and I-CVI over 0.80 were kept, ranged from 0.70 to 0.78 were revised, and below 0.70 were rejected. Items with kappa values ranging from 0.04 to 0.59 were revised and ≥0.74 were retained. Internal consistency assessed using Cronbach's alpha was 0.449. Positive correlation between attitude and communication (r = 0.448), between performance and communication (r = 0.443) were statistically significant at 0.01 level. Overall, intraclass correlation coefficient for all the measures is 0.646, which is statistically significant at 0.05 level (P < 0.05). CONCLUSIONS: Study concludes that the RadEM-PREM IPE tool would be a new measuring tool to assess knowledge, performance, and communication skills of interprofessional radiation emergency response team learner's evaluation.

Perceptions of novel warnings compared with current warning on tobacco packs, and warnings on cigarette sticks: A cross-sectional survey of college students in Southern India.

INTRODUCTION: In India there is insufficient knowledge of the risks associated with tobacco use. Increasing awareness of these risks is critical, with pictorial warnings on tobacco packs a cost-effective way to communicate this information. We explored perceptions of the current warning, 'Tobacco causes cancer', displayed on packs in India and four novel warnings about other potential impacts of tobacco use including social, financial, and environmental, but also complications with diabetes. As loose cigarette sales are common in India, we also explored perceptions of warnings on cigarette sticks. METHODS: A cross-sectional survey of college students aged ≥18 years in Karnataka, India, was conducted between January 2019 and February 2020. Participants were asked about salience, believability, and cognitive processing of warnings currently on packs. They were then shown an image of one current and four novel warnings and asked about their perceived effectiveness in preventing uptake and reducing and stopping tobacco use. They were then asked about warnings on cigarette sticks. RESULTS: Most participants (70.2%) recalled warnings on packs and considered them believable (55.7%), but only 12.0% read and 12.4% thought about them often. Warnings about the health impacts of tobacco use were viewed as most effective in preventing uptake, and reducing and stopping tobacco use. Nevertheless, at least a third of participants rated warnings pertaining to financial, social, and environmental impacts effective in preventing uptake, and reducing and stopping tobacco use. Approximately one-fifth (22.0%) thought that warnings on cigarette sticks would deter initiation. CONCLUSIONS: Our results suggest that health warnings are perceived as most effective in discouraging tobacco use among college students in Karnataka. While viewed as less effective than health warnings, novel non-health related messages were viewed as effective in preventing uptake, and reducing and stopping tobacco use by at least one in three participants. Warnings on cigarette sticks may help complement warnings on cigarette packs.

Recognising the importance of chronic lung disease: a consensus statement from the Global Alliance for Chronic Diseases (Lung Diseases group).

BACKGROUND: Chronic respiratory diseases are disorders of the airways and other structures of the lung, and include chronic obstructive pulmonary disease (COPD), lung cancer, asthma, bronchiectasis, interstitial lung diseases, occupational lung diseases and pulmonary hypertension. Through this article we take a broad view of chronic lung disease while highlighting (1) the complex interactions of lung diseases with environmental factors (e.g. climate change, smoking and vaping) and multimorbidity and (2) proposed areas to strengthen for better global patient outcomes. CONCLUSION: We suggest new directions for the research agenda in high-priority populations and those experiencing health disparities. We call for lung disease to be made a research priority with greater funding allocation globally.

A close critical look of India's National Mental Health Survey 2016.

The National Mental Health Survey 2016 (NMHS 2016) was a large epidemiological study, one of its kind, conducted by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru to overcome the shortcomings of the previous surveys. The detailed report of the study is available in two parts- 'mental health systems' and 'prevalence, pattern and outcomes'. Though done comprehensively, there are some inevitable limitations. The private sector, a substantial health care provider in the country was not a participant in the survey. Though MINI version 6.0 is a standard and structured instrument, it does not cover many commonly encountered mental illnesses like somatoform disorders. Further, the methodology of the survey makes it difficult for an accurate calculation of the prevalence of individual major psychiatric disorders. The survey has been appraised using a standard checklist for prevalence studies. The detailed qualitative data has not been shared in the report. The contribution of the traditional indigenous systems of healthcare and accessibility of services in rural areas have not been elaborated. Thus, the need for a comprehensive and culturally sensitive assessment tool, involvement of the private sector, and enhancing funding provision to improve the infrastructure are emphasized as future directions for the subsequent phases of the survey.

Universalization of Healthcare for Non-Communicable Diseases in India - Promise of Health and Wellbeing, Insurance for Universal Health Coverage.

SUMMARY: Noncommunicable diseases (NCDs) pose a significant global health and economic burden, necessitating universal health coverage (UHC). Out-of-pocket (OOPs) payments for healthcare, particularly in low- and middle-income countries lacking social protection and health insurance, contribute to impoverishment and catastrophic expenditure. This scoping review aimed to assess the state of UHC for NCDs in India, including the progress made, coverage of government health insurance schemes, challenges faced, and their potential solutions. A literature search was performed in major databases such as PubMed, Ovid, Web of Science, Embase, Cochrane Library, and Google Scholar using appropriate keywords. Findings indicated that UHC remains a distant dream in India with a disproportionately high NCD burden and a substantial portion of health-care expenses (80% outpatient, 40% inpatient) relying on OOP expenditures, causing financial hardship. Limited universal social security exacerbates health-care access challenges. The coronavirus disease-2019 pandemic has further hindered NCD services and UHC progress. The Ayushman Bharat program, featuring health and wellness centers and the Pradhan Mantri Jan Arogya Yojana, aims to address primary health-care needs and provide NCD coverage in India. Despite this, challenges persist, including inadequate availability of essential medicines and technologies in health-care facilities, as well as gaps in rural health-care access. Telemedicine services like "eSanjeevani" have been implemented to improve access in remote areas. To achieve UHC for NCDs in India, it is crucial to strengthen primary health-care, ensure medicine availability, enhance human resources, establish a referral system, address social determinants, and implement social protection.

Impact of closure of educational institutions due to COVID-19 lockdown on overall subjective wellbeing of adolescents and youth: Cross-sectional survey, India.

Background: Students were confined to their homes due to the national closure of educational institutions during the COVID 19 pandemic, thus presenting an unprecedented risk to children's education, protection, and wellbeing. Aim: This study aimed to understand the determinants of subjective wellbeing of adolescents and youth (aged 11-21 years) during the COVID-19 pandemic in India. Materials and methods: A cross-sectional web-based survey was adapted, pre-tested, and finalized to obtain the participant's responses from schools and colleges. Participants aged 11-17 years were engaged through schools. Consent procedures were followed. The survey link was disseminated through social media for the participants aged 18-21 years. The survey was made available in English and Hindi. The data was collected from March-June, 2021. Results: Overall, 1,596 students completed the survey. Out of 1,596 students, 1252 (78%) were below 18 years and 344 (21.5%) participants were 18 years and above. Results suggest a statistically significant (p < 0.01) difference in the level of student's life satisfaction before and during the COVID-19 pandemic. Of the students who were dissatisfied with their general life during the pandemic, nearly 63.4% felt sadness followed by other feelings, i.e., boredom (around 60.5%), loneliness (63.7%), and anxiety (62.2%). Conclusion: This study highlights the need for innovative strategies for adolescents and parents to adopt and promote overall subjective wellbeing, especially during public health crises such as the COVID-19 pandemic.

Tobacco prevention and control interventions in humanitarian settings: a scoping review protocol.

INTRODUCTION: Tobacco has been a complex global problem that has adversely affected almost all the sectors of society. However, the ill-effects are often most reflected in humanitarian settings, which inadvertently are surmounted by fragile systems. We aim to map tobacco prevention and control intervention in humanitarian settings. METHODS AND ANALYSIS: This scoping review will follow the guidelines of the Joanna Briggs Institute. A comprehensive search strategy was designed using Medical Subject Heading terms, subject experts and pertinent reviews. The search was conducted on Medline (through PubMed and Ovid), EMBASE (through OVID), ProQuest Health and Medical Complete, EBSCO (through CINAHL Complete), Scopus and Web of Science databases. Two reviewers will independently screen the identified studies on removing duplicates, which shall be followed by data extraction using a pretested data extraction form. A narrative synthesis approach will be employed to collate the findings from the studies and tabular formats would be used to aid the representation. ETHICS AND DISSEMINATION: This review will identify, map and synthesise the interventions for tobacco prevention and control in the humanitarian settings. An ethics committee approval was not sought for this body of work as it does not include human subjects. Results from the study will be disseminated through conference presentations and peer-reviewed publications.

The association between the retail price of manufactured cigarettes and bidis on current smoking status in India.

INTRODUCTION: In India, the retail prices of bidis and cigarettes varied between the two Global Adult Tobacco Surveys (GATS) conducted in 2009-2010 and 2016-2017. The relationship between the retail price of smoked tobacco products and their use is unclear for India. Our study thus aimed to use available datasets to investigate the association between the retail price and current smoking status of bidis and cigarettes in India. METHODS: Current smoking status data for bidis and cigarettes were obtained from the two GATS rounds. The average state-level retail prices of bidis and cigarettes were obtained from India's Consumer Price Index- Industrial Workers database. Descriptive statistics were used to describe current smoking status patterns. Generalized Linear Mixed Models were used to investigate the association between the retail prices and current smoking status of bidis and cigarettes. RESULTS: For cigarettes, an increase in the average retail price by one Indian Rupee was associated with a reduction in the odds of being a current smoker of 7% (OR=0.925; 95% CI: 0.918-0.932, p<0.001). For bidis, the association between the retail price and current smoking status was not statistically significant (OR=1.01; 95% CI: 1.00-1.02, p=0.082). CONCLUSIONS: Current increases in the retail prices of tobacco products in India seem to have an impact on the use of cigarettes but not bidis. This highlights the need for tobacco product tax increases that result in sufficient retail prices increase to make all tobacco products less affordable and reduce their use.

Strengthening tobacco control policies during the COVID-19 pandemic in India.

Problem considered: The aim of this paper was to support policy makers to make informed decisions regarding public health response in general, and tobacco control interventions particularly, in the context of COVID-19. Methods: An online cross-sectional survey using a semi-structured questionnaire was conducted in the year 2020 with stakeholders in tobacco control and public health experts from private and government organizations. Information pertaining to background characteristics of study participants and impact of pandemic on tobacco use and means to leverage tobacco control policy was collected. Data was analysed using Microsoft excel 2010 and results are presented as frequencies and percentages along with key responses from open ended questions. Results: A total of 72 stakeholders were approached out of which, 46 (56.1%) responded and were included. About 32 (74.4%) of the participants thought that public health authorities had given advice on stopping tobacco use during COVID-19 pandemic. About 19 (43.2%) participants did not notice any change in level of interest in tobacco cessation during the pandemic while a majority 34(73.8%) agreed that COVID-19 pandemic had an impact on health seeking behaviour of patients with non-communicable diseases. Nearly half of participants, 21(48.8%) opined that tobacco industry was engaged in corporate social responsibilities during COVID-19. Conclusion: The stakeholders expressed that there is a good opportunity to further strengthen tobacco control activities during COVID-19 pandemic and also emphasized need to closely monitor tobacco industry interference during this time.

Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India.

INTRODUCTION: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression. RESULTS: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]). CONCLUSIONS: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising. IMPLICATIONS: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

Institutional tensions, corporate social responsibility and district-level governance of tobacco industry interference: analysing challenges in local implementation of Article 5.3 measures in Karnataka, India.

INTRODUCTION: Accelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level. METHODS: Based on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels. RESULTS: Our analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations. CONCLUSIONS: Promoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India's national health and economic priorities.

Outcome of structured health education intervention for obesity-risk reduction among junior high school students: Stratified cluster randomized controlled trial (RCT) in South India.

BACKGROUND: Obesity has been identified as a serious global health concern whose prevalence doubles almost every 10 years. Health education regarding physical activity and healthy diet imparted to adolescents could prove to be fruitful in reducing obesity-risk. Objectives of this study were to evaluate the effect of health education intervention on knowledge, attitude, and practices (KAP) regarding obesity-risk reduction and to estimate the postinterventional change in body mass index (BMI) and total body fat (%) among adolescent school children in South India. MATERIALS AND METHODS: Stratified cluster randomized controlled trial was carried out among 398 students recruited at baseline including 206 and 192 participants in intervention and control group respectively selected through simple random sampling from eligible government aided and private schools to assess KAP regarding physical activity and diet using pretested and validated questionnaire by making three school visits 6 months apart. Anthropometric measurements were recorded in first and third visit only, while health education intervention was given in first visit to intervention and third visit to control group after taking their responses on the questionnaire. Data were entered and analyzed using SPSS version 15. RESULTS: Overall dropout rate was 13.5% with dropout in intervention and control group being 12.6% and 14.5% respectively, making 180 participants in intervention and 164 in control group available for analysis. Mean physical activity KAP score improved significantly from 16.19 ± 4.61 to 19.46 ± 10.07 in intervention group. Mean dietary KAP score also improved significantly from 21.38 ± 4.07 to 23.43 ± 4.53 in intervention group (p < 0.001). Mean BMI decreased significantly within intervention group (p < 0.001) as compared to control group (p = 0.908). Based on cut-off level for total body fat (%) to categorize obesity-risk among participants, statistically significant decline in proportions from 26.1% to 13.3% was observed in intervention group (p < 0.001). CONCLUSION: Results depicted better KAP in intervention group than control group in all the three visits while it improved significantly within both groups. Hence, the health education was found to be effective in improving the overall KAP regarding modifiable risk factors of obesity among the study participants. Further studies to screen the adolescents for obesity-risk and successive health education sessions must be carried within schools in order to bring about change in knowledge, attitude, and practices regarding obesity-risk.

Implementation of Article 5.3 of the World Health Organization Framework Convention on Tobacco Control: A Subnational Assessment.

Background: Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control necessitates the governments to take measures to protect health policy from the commercial and other vested interests of the tobacco industry (TI). Considering the vast geographical area and diversity between states within India, it is necessary to evaluate the level of implementation of Article 5.3 at the sub-national level. Hence, this study was conducted to assess the implementation of Article 5.3 in the Karnataka state of southern India. Materials and Method: Southeast Asia Tobacco Control Alliance Tobacco Industry Interference index was adopted and used for the study. A desk review was conducted for 2018. Publicly available evidence of tobacco industry interference was scored based on its frequency, severity, and the government's response to it. Lower the score, effective the level of governance against the TI interference, which predicts well for the state. Results: The study demonstrates a score of 46 out of 95 in the implementation of Article 5.3 in Karnataka, which is lower when compared to the national score of 69 out of 100 for 2018. Corporate social responsibility, conflict of interest, and unnecessary interactions with TI are the major areas that need focus to comply with the provisions of Article 5.3. Conclusion: Overall, Karnataka needs to strengthen the implementation of Article 5.3 and develop a strategy in line with the global best practices. This assessment can help in identifying areas requiring enhanced vigilance to avoid industry interference.

Prospective cohort study of exposure to tobacco imagery in popular films and smoking uptake among children in southern India.

BACKGROUND: Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. METHODS: We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. RESULTS: We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. CONCLUSION: Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries.

Beedi Rollers' Perception toward Alternative Means of Livelihood amid Economic Benefits.

BACKGROUND: Beedi rolling is one of the principal occupations of women residing in coastal Karnataka. The beedi worker's welfare fund consists of a combination of schemes to improve the living conditions of beedi workers and their families. On the other hand, the government is introducing several anti-tobacco policies, which could lead to insecurity among beedi rollers about their future. As a result, majority of the trade unions believe that alternate livelihood must be provided to the workers. In the midst of economic benefits and stringent tobacco control policies, this study explores the perception of beedi rollers to quit tobacco rolling and engage with an alternative livelihood. OBJECTIVES: The objectives of this study were as follows: (1) to explore the opinion of beedi workers toward alternate means of livelihood and (2) to identify the benefits availed by the beedi workers. METHODOLOGY: The study was conducted with a semi-structured questionnaire by interview method in all the seven blocks of the Udupi district of Karnataka with a total of 381 respondents through convenience sampling. The interviewer administered the survey with the help of a predesigned user application which was developed through Kobo Toolbox, and the analysis was carried out using IBM SPSS version 26. RESULTS: Although 69% of the respondents believed that beedi rolling is not a secured job, three-fourth of the respondents were not ready to quit the beedi rolling job due to low education, higher age, and lack of financial support to invest in other occupations. CONCLUSION: Our study showed that most of the participants were full-time beedi rollers and most of them were not ready to shift to other jobs due to old age, lack of experience with other vocations, and benefits availed. There is a need to focus on strengthening skill development programs and introduce sustainable economic alternatives to the beedi rollers.

Quantifying audio visual alcohol imagery in popular Indian films: a content analysis.

OBJECTIVES: Though exposure to alcohol imagery in films is a significant determinant of uptake and severity of alcohol consumption among young people, there is poor evidence regarding the content of alcohol imagery in films in low-income and middle-income countries. We have measured alcohol imagery content and branding in popular Indian films, in total and in relation to language and age rating. DESIGN: In this observational study we measured alcohol imagery semiquantitatively using 5-minute interval coding. We coded each interval according to whether it contained alcohol imagery or brand appearances. SETTING: India. PARTICIPANTS: None. Content analysis of a total of 30 national box office hit films over a period of 3 years from 2015 to 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: To assess alcohol imagery in Indian films and its distribution in relation to age and language rating has been determined. RESULTS: The 30 films included 22 (73%) Hindi films and 8 (27%) in regional languages. Seven (23%) were rated suitable for viewing by all ages (U), and 23 (77%) rated as suitable for viewing by children subject to parental guidance for those aged under 12 (UA). Any alcohol imagery was seen in 97% of the films, with 195 of a total of 923 5-minute intervals, and actual alcohol use in 25 (83%) films, in 90 (10%) intervals. The occurrence of these and other categories of alcohol imagery was similar in U-rated and UA-rated films, and in Hindi and local language films. Episodes of alcohol branding occurred in 10 intervals in five films. CONCLUSION: Almost all films popular in India contain alcohol imagery, irrespective of age rating and language. Measures need to be undertaken to limit alcohol imagery in Indian films to protect the health of young people, and to monitor alcohol imagery in other social media platforms in future.